COVID-19 infections are a new challenge to the world. Severe patients
have a significant higher morbidity and mortality compared with non-severe
ones. In response, the Chinese Society for Parenteral and Enteral Nutrition
(CSPEN) formulated this multidisciplinary consensus, calling on integrate
medical nutrition therapy into routine care for COVID-19 infections as follows.

CSPEN hopes this consensus will also help the other countries in fighting
with COVID-19 infections.

Key words: COVID-19 infections; severe patients; nutrition therapy;

As of 11:00 a.m. on February 24, 2020, Chinese officials had recorded 77,262
confirmed cases of COVID-19-associated pneumonia which has been classified as
non-severe and severe two categories by Nan-Shan Zhong(1), with a reported 15.7% to 25.5% of severe
patients reported in the literature(1, 2), there were 12,130 to 19,702 severe patients.
Compared with non-severe patients, severe patients have a higher mortality rate
(8.1% vs.1.4%), a higher incidence of complications (pneumonia: 94.8% vs.
76.1%, ARDS: 15.6% vs. 11%, septic shock: 6.4% vs. 0%, acute renal injury: 2.9%
vs. 0.1%), require more treatment (intravenous antibiotics: 80.3% vs. 53.2%,
oseltamivir: 46.2% vs. 33.8%, systemic corticosteroids: 44.5% vs. 13.7%,
mechanical ventilation: 38.7% vs. 0%, immunoglobulin: 32.9% vs. 9.3%), and are
more likely to enter the ICU (19.1% vs. 2.4%)(1). This indicates that severe patients are the
focus of treatments because of their poorer prognosis. These patients are also more
difficult to treat, and consume more manpower, materials and financial
resources. COVID-19 infections are a new challenge, and there are no
evidence-based therapeutic guidelines to follow. Learning from past experiences
in the treatment of influenza, HIV, MERS and SARS(3-5), and following the recommendations of the
Academy of Nutrition and Dietetics supporting the integration of medical
nutrition therapy into routine care for the HIV population(5), the Chinese Society for Parenteral and
Enteral Nutrition (CSPEN) recently formulated a “consensus on nutrition
therapy for severe patients with COVID-19 infections” in order to improve
the treatment of these patients.

1. Nutrition support teams (NST)

Recommendation 1: Set up NST, which should be
routinely involved in the treatment of severe patients

Due to the lack of proven specific
treatments, improving immunity, controlling symptoms and providing supportive care
remain the main measures for treating COVID-19 infection(6). Nutrition is the key to human immunity, and
nutrition therapy should become part of the routine care and a major means for improving
the outcome of patients with COVID-19 infection, especially for severe patients(7). The establishment of a NST is considered to
be the most effective measure to implement nutrition therapy, which has been
shown to effectively shorten the length of stay (LOS) in the hospital, LOS in
the ICU and the duration of mechanical ventilation for critically-ill patients(8).

The NST, which should be comprised of clinicians, dietitians, clinical
pharmacists, nurses, et al., should become a core of the multidisciplinary team
that treats severe patients with COVID-19 infections. In particular, the duty of
the NST is to accurately identify the patients at nutritional risk or with malnutrition,
to formulate a reasonable nutrition therapy plan, and to monitor and evaluate
the effects of the nutrition therapy(9, 10).

Obtaining an accurate diagnosis of the
nutrition status is the foundation of nutrition therapy. Before initiating systematic
treatment, the nutritional status of all patients with COVID-19 infection
should be investigated as a routine(11). The nutrition diagnosis should be carried
out step-by-step using any validated tool. Screening should be carried out
first to identify “at risk” status, then the nutrition assessment should
confirm the diagnosis of malnutrition and grade its severity and the third should
be a comprehensive investigation of the physical, physiological and
psychological effects of malnutrition (figure 1)(12). It is recommended that the NUTRIC or
modified NUTRIC be used for nutrition risk screening(13-15), followed by the SGA(13, 16) or GLIM(17, 18) for nutrition assessment. Clinical
observations found that compared with non-severe patients, severe patients have
more underlying diseases (37.6% vs. 20.5%), more lung X-ray changes (26.65 vs. 12.5%),
higher hematological abnormalities (white blood cells, lymphocytes, platelets
and hemoglobin) and more functional impairments (liver function, renal
function, lung function)(1, 2). Therefore, it is necessary to perform a third
round of diagnosis, i.e. a comprehensive investigation analyzing malnutrition from
four dimensions (energy expenditure, stress levels, inflammatory responses, and
metabolic status), and also investigating the effects of malnutrition at five
levels (body composition, physical fitness, organ function, psychological
status, and quality of life)(19).

3. Energy and protein

Recommendation 3: The caloric intake should
be 15 to 30 kcal/kg/day, the ratio of energy derived from glucose to that from
lipids should be 50%-60%/40%-50%; the protein intake should be 1.2-2.5
g/kg/day, and the nonprotein calorie-to-nitrogen ratio should be 100-150 kcal:1
g.

Fever (87.9% – 98.6%), cough (59.4% – 82.0%),
muscle pain and fatigue (44% – 69.6%) are the most common symptoms of
hospitalized patients with the COVID-19 infection(1, 20-22). Severe patients have a higher body
temperature, more severe shortness of breath, a greater likelihood of having an
increased C-reactive protein level (>10 mg/L: 81.5% vs. 56.4%) and
procalcitonin level (>5 ng/ml: 13.7% vs. 3.7%), higher levels of
inflammatory mediators (IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, TNF) at
admission(1, 20-22), and an albumin level that continues to
decrease after admission(23). All the above information suggests that the
energy expenditure and protein catabolism of severe patients with COVID-19 infections
are higher, so their nutrition therapy should be different from that of non-severe
patients, particularly with regard to the energy supply and protein content of
the diet. Although the daily energy expenditure (EE) of critically-ill patients
may exceed 50% of the normal resting energy expenditure (REE), which is
equivalent to 36 kcal/(kg·d), studies have found that the REE of most
critically-ill patients is normal, which equates to 22-25 kcal/kg/day. Because
most critically-ill patients are inactive, the average REE is closer to the
total daily energy expenditure (TDEE)(24). Considering the diversity of severe
patients, the CSPEN recommends a broad range of energy consumption, from 62.7~125.4
kJ (15~30 kcal/kg/day). Patients with severe malnutrition, obesity, and acute
phase disease (within 4 days after entering the ICU) are recommended to gradually
increase their energy supply to more than 80% of the estimated energy needs
within 3-7 days, starting with 62.7kJ (15 kcal/kg/day)(24-26). The protein supply is different from the hypocaloric
energy supply in the acute phase in patients with severe infections, and we
emphasize that the early provision of an adequate supply of protein (1.2-2.5 g/kg/day)
is necessary. The calories administered to patients on mechanical ventilation
can be calculated based on the carbon dioxide production (VCO2) ×
8.19. It is recommended that the caloric needs be calculated using an indirect
calorimetry metabolic cart system if conditions permit(24-26).

4. The five-step ladder of nutrition therapy

Recommendation 4: Nutrition therapy should
adhere to the five-step ladder model, starting from nutritional counseling/dietary
modification and increasing step-wise to total parenteral nutrition, following
the ‘50% principle’ to ensure a smooth nutrition ladder transition.

The first step of nutrition therapy is oral diet nutritional counseling/dietary
modification. Artificial nutrition (enteral nutrition, parenteral
nutrition) is chosen only when the diet is insufficient; the first choice of
nutrition route is the trans-oral approach, such as ONS. Tube feeding is chosen
only when the oral intake is insufficient. Enteral nutrition is the first
choice of artificial nutrition, and parenteral nutrition is chosen only when
enteral nutrition is insufficient. If the treatment lower on the ladder cannot
meet 60% of the targeted energy requirement for 2-3 days, the treatment on the
next rung of the ladder should be applied. The nutrition ladder transition for severe
patients, i.e. the bottom-up and top-down models in the five-steps ladder,
should be switched or transitioned smoothly following the ‘50% principle’ ,
which means that when enteral nutrition can meet 50% of the target demand,
parenteral nutrition should be gradually reduced or stopped while enteral
nutrition should be gradually increased; when an oral diet can meet 50% of the target
demand, enteral nutrition should be gradually reduced or stopped while the oral
diet should be increased gradually; conversely, when 50% of the target demand
cannot be met, the parenteral nutrition or enteral nutrition must be continued.

Cytokine storm and hypermetabolism organ
failure complex (HMOFC) are serious conditions that occur in association with many
infectious or non-infectious diseases such as MERS, sepsis, and malignancy(31-34). Cytokine storm and HMOFC have also been
documented in some patients with the new coronavirus infection, and were
important contributors to the patients’ deaths. Severe patients have more
severe stress reactions, more significant metabolic disorders, higher levels of
inflammatory factors, and faster disease changes(1, 20, 22), highlighting the importance of maintaining
metabolic homeostasis and regulating inflammatory responses. In addition to
traditional antiviral therapy and glucocorticoid therapy, severe patients also
need metabolic support and inflammation regulation therapy as follows: (1)
Reduce the energy load, providing 10-15 kcal/kg/d or <30%-50% of the target
requirement during the severe acute phase, in cases with hemodynamic
instability, ARDS, etc.(35-37), (2) Increase the protein and branched-chain
amino acids (BCAA) supply, using supplements if necessary, and inhibit
catabolism. It is recommended that 1.5-2.0 g (1.8-3.0 g free amino acids)/kg/d(24, 36) be provided to such patients, and the BCAA
ratio should be increased to 35%, which can not only significantly inhibit
muscle breakdown(38), but also improve insulin resistance(39) and enhance the efficacy of interferon(40), (3) Inhibit excessive inflammation and
regulate immune function. The use of N-3 fatty acids in critically-ill patients
can reduce the risk of death, infection, and hospital LOS(41), (4) Inhibition of free radicals to reduce
peroxidation damage. The intravenous injection of vitamin C at 3~10 g/d
significantly reduced mortality and shortened the use of booster drugs and the
need for a ventilator in critically-ill patients(42). The administration of vitamin C may become a
standard treatment for patients with sepsis(43) and is effective for patients with virus-associated
ARDS(44), (5) Reduce the intestinal load by limiting volume
overload and enhancing bowel movement, inhibition of endotoxin release into the
bloodstream. Apply tropical enteral nutrition early, and add dietary fiber and
prebiotics on an individual basis. (6) Reduce fluid load, especially I.V.
fluid.

6. Enteral nutrition

Recommendation 6: Early implementation of
enteral nutrition (EN), with an emphasis on ONS.

Gastrointestinal dysfunction in patients with
COVID-19 infection is relatively rare, and the incidence of diarrhea and
vomiting being only 3.7% and 5.0%, respectively(1). It is thus possible to implement enteral
nutrition for most COVID-19 patients. Enteral nutrition should be implemented
according to the individual’s condition, gradually transitioning from a predigested
formula to a whole protein formula or homogenate preparations. Patients with gastrointestinal
dyspepsia may benefit from the administration of short peptide or amino acid formulas.
Early enteral nutrition (EEN) can regulate the balance of Th17/Treg cells,
inhibit the IL-23/IL-17 axis, reduce the clinical severity of sepsis(45), and reduce infectious complications in critically-ill
patients. However, it is recommended that EN be delayed for critically-ill
patients with uncontrolled shock, uncontrolled hypoxemia and acidosis,
uncontrolled upper GI bleeding, gastric aspiration >500 ml/6 h, bowel
ischemia, bowel obstruction, abdominal compartment syndrome, or a high-output
fistula without distal feeding access(46). When EEN was initiated within 48 hours of
admission to the ICU, there was a significant improvement in the clinical
prognosis compared to when it was initiated after 48 hours(46). EN is safe and effective in patients with
severe pancreatitis within 24-48 hours, which provides more benefit than
delayed enteral nutrition(47, 48). ONS should be given if the oral diet fails
to achieve 60% of the energy and protein targets, with a recommended daily
supplementation of 400-600 kcal in addition to the oral diet(49, 50). Proper EN, such as ONS, shortens the length
of hospitalization, reduces the episode costs, and reduces the 30-day
readmission risk(27). However, EN alone is typically unable to fulfill
the target requirements for critically-ill patients. A multi-institutional,
prospective study of 3,390 mechanically-ventilated patients at 201 centers from
26 countries found that EN was started on average 38.8 hours after admission. The
majority (74.0%) of patients did not meet at least 80% of their target energy, with
only 61.2% of the energy and 57.6% of the protein prescribed being delivered to
patients(51). Critically-ill patients prescribed enteral
nutrition alone have a higher risk of malnutrition (OR = 3.77, 95% CI =
2.71-5.24)(9). Combining enteral nutrition and parenteral
nutrition is more likely to achieve target requirements(52), reduce infectious complications, reduce 30 day
death(52, 53), and improve the patient’s nutritional
status and clinical outcomes(52, 53).

Recent studies have found that the vast
majority of critically-ill patients do not meet the 60% target requirement(54). Similar to other diseases, the severe patients
with COVID-19 infections may be unable to meet the target nutritional
requirements via an oral diet and/or enteral nutrition. Even worse, many widely-used
antiviral drugs have severe adverse gastrointestinal effects, which may prevent patients from eating or digesting
oral nutrition. A negative energy balance (energy deficit) has been shown to
increase infectious complications, the length of hospital stay, and duration of
time on a ventilator(52, 54), so parenteral nutrition has become a
necessary support for severe patients with COVID-19 infections(55). When enteral nutrition cannot meet 60% of
the target energy and protein within 48-72 hours, it is recommended that SPN be
provided as soon as possible, because it can improve the clinical outcomes and
decrease the medical costs(56-59). An all-in-one formula is recommended over multi-bottle
infusions, as commercial multi-chamber bags have many advantages(60, 61) although some patients need an individualized, all-in-one parenteral nutrition formula(62). PN is more likely to improve the patient’s nutritional
status, and also has a positive effect on disease treatment and successful
weaning from a ventilator, helping patients to survive the dangerous acute
infection period and promoting their rehabilitation(55, 63). However, it is necessary to monitor the
metabolic status frequently and adjust the PN prescription to prevent
overfeeding(64).

8. Formulation selection

Recommendation 8: Increase the proportion of lipids
and amino acids in the PN while reducing the proportion of glucose.
Preferentially, choose medium- and long-chain lipid emulsions, and increase the
omega-3 and omega-9 fatty acid content. Choose general formulas for EN, while
disease-specific formulas are recommended for patients with coexisting conditions.

The PN formula for severe patients with COVID-19
infections requires an increase in the proportion of lipids and amino acids, and
a reduction in the proportion of glucose. Preference should be given to medium-
and long-chain lipid emulsions, and there should be an increase in omega-3 and
omega-9 fatty acids. Increasing the proportion of fat in the PN solution may
increase the success rate of weaning from the ventilator and shorten the
mechanical ventilation time. The inclusion of omega-3 fatty acids in PN can significantly
decrease the production of inflammatory factors, triglyceride levels, and liver
enzymes(65), improve gas exchange, reduce infectious complications,
shorten the length of total hospitalization and reduce the ICU stay(66). In addition, the use of PN has shown
significant benefits pharmacoeconomically(67). The immune-neutral effects of ω-6:ω-3 =
2.1: 1 can prolong the survival time of transplanted organs, and may similarly
protect native organs from stress(68). The above studies suggest that omega-3
fatty acids are beneficial for preventing cytokine storm and HMOFC in severe
patients with COVID-19 infections. The addition of alpha-tocopherol can enhance
the anti-inflammatory effects of omega-3 fatty acids(69). Omega-9 fatty acids have immune-neutral and
low-inflammatory properties, and are rich in alpha-tocopherol. Long-term use of
omega-9 fatty acids can increase oxidized glutathione and protect the liver
function(70). The injection of antioxidant-free amino
acids may be safer for severe patients with COVID-19 infections, and should be
considered for those unable to sustain a sufficient intake via other means(71).

General EN formulations are
preferred over disease-specific formations except in those with comorbid or
coexisting diseases. For those with diabetes, diabetes-specific food for
special medical purpose (FSMP) is recommended. FSMP with a low sugar and high
fat content may be a better choice for diabetic patients with respiratory
insufficiency. Tumor-specific FSMP may benefit more for patients with advanced
cancer(72, 73). Immune-modulated nutritional preparations
can theoretically promote the recovery of critically-ill patients(74-77). Dietary fiber, prebiotics, probiotics, etc.
have certain effects, including the induction of flatulence, diarrhea, and a microecological
balance, they could be used on an individualized consideration, especially for
probiotics. Homogenate diets from dark green vegetables, fruits, and beans, are
rich of antioxidants such as vitamin C, vitamin E, carotenoids, and selenium can
reduce oxidative stress-related damage(78).

9. Nutrition therapy for comorbidities

Recommendation 9: Attention
should be paid to nutrition therapy that can address life-threatening
complications and comorbidities.

According
to the report by Nan-Shan Zhong et al.(1), hypertension (14.9%) and diabetes (7.4%)
are the two most common comorbidities. Pneumonia (79.1%) and ARDS (3.4%) are
the two most common complications. All other conditions and complications were
found in fewer than 3% of cases. However, compared to non-severe patients, severe
patients with COVID-19 infections had an older average age (52 yr. vs. 45 yr., P<0.001),
more comorbidities (hypertension: 23.7% vs. 13.3%, diabetes: 6.2% vs. 5.7%),
and a higher incidence of complications (pneumonia: 94.8% vs. 76.1%, ARDS:
15.6% vs. 1.1%). These observations emphasize that providing nutrition therapy targeting
these comorbidities and complications is of great importance in severe patients
with COVID-19 infections. The specific indications for these conditions are
described below:

ARDS:
Clinical observations have shown that ARDS is the leading cause of death in severe
patients with COVID-19 infections. Nutrition therapy for ARDS follows the
general principles of metabolic support and inflammation regulation described
above, including inhibiting the inflammatory response, reducing the metabolic
load and inhibiting catabolism. It is essential to perform trophic EN(79-81), controlled underfeeding of PN, to provide sufficient
BCAA(82), moderate addition of omega-3 fatty acids,
and to include dietary fiber. A subgroup analysis within a meta-analysis showed
that moderate underfeeding of EN reduced the overall mortality in patients with
acute respiratory failure(80). Compared to septic shock patients without
EN or those receiving ≥600 kcal/d EN, those receiving EN <600 kcal/d starting
within 48 hours of admission had a significantly reduced mechanical ventilation
time and ICU hospital stay(81). Short-term (2 consecutive days) oral intake
of 14.4 g BCAA significantly improved the respiratory quotient (RQ), while continuous
oral intake for 30 days significantly improved the handgrip strength without
increasing the oxygen consumption (VO2) and heat production(82). Supplementation of omega-3 fatty acids
significantly and continuously improved the PaO2/FiO2
ratio in ARDS patients, and there was also a tendency toward a reduced duration
of mechanical ventilation and ICU hospital stay(83).

Hypoproteinemia: It has been reported that 83% of severe
patients with COVID-19 infections have elevated C-reactive protein levels(84) and 50% of patients had decreased albumin level
at admission, with a continuous drop after admission(23). Albumin has a variety of physiological
functions, such as maintaining the colloid osmotic pressure, serving as a carrier
for a variety of biological substances, scavenging free radicals, being an
antioxidant, and anti-platelet aggregation. Hypoalbuminemia may indicate (1) poor
nutritional status, (2) reduced antioxidant, anti-free radical, and
detoxification capabilities, and (3) severe acute inflammation(85), all of which lead to a poor clinical
prognosis. Hypoalbuminemia also alters the pharmacokinetics and
pharmacodynamics of albumin-carried drugs, including antibiotics(86, 87). Intravenous albumin infusion has limited
efficacy and is associated with many adverse reactions, hence it should be as
per individual condition, but not be the first choice of hypoalbuminemia treatment(88). Rather, administering EEN rich in protein provides
a better solution(89).

Diabetes/Hyperglycemia:
Hyperglycemia is a well-known indication of a poor clinical prognosis(90). High glycemic variation (mean amplitude of
glycemic excursions (MAGE) >65 mg/dL) within 24 hours of ICU admission is an
independent risk factor for an increased 30-day mortality(91). Therefore, the management of blood glucose
in critically-ill patients, especially those with diabetes, includes two
aspects: blood glucose control and blood glucose stabilization(92). The American Academy of Internal Medicine
recommends that the blood glucose of ICU patients be maintained at 7.8-11.1 mmol/L
(140-200 mg/dL) but not less than 7.8 mmol/L (<140 mg/dL) with insulin
administration(90). Hypoglycemia is also an important cause of
death; therefore, the blood glucose levels should be continuously and dynamically
monitored to avoid dramatic fluctuations(92, 93).

The average blood
glucose concentration and glycemic variability of diabetic critically-ill
patients have not been found to have an association with ICU death, which is
different from patients without diabetes. Nonetheless, hypoglycemia, with a
cutoff point of ≤2.2 mmol/L, is related to ICU death for both non-diabetics and
diabetics(93). The cut-off points for low glucose are
different for non-diabetics and diabetics, namely 4.9 mmol/L and 3.5 mmol/L,
respectively(93).

Nutritious formula with low glucose and high-fat
content that is rich in fiber helps control blood glucose, reduce insulin requirements,
and lowers the risk of hypoglycemia. Nutrition therapy prescribed by a
registered dietitian (RD) plays an important role in diabetes management(94).

(4) Hypertension: Hypertension being the most
common comorbidity in patients with COVID-19 infections may be due to its high
incidence among the population, rather than being condition-specific. Although
the rate of hypertension in severe patients with COVID-19 infections is higher
than that of non-severe patients, it may be related to the older age of these patients
rather than the disease status. The provision of nutrition therapy for
hypertension in severe patients with COVID-19 infections should follow the
principles of nutrition therapy for general hypertension patients. This may
include but not limited to discarding eating habits that make the subject prone
to hypertension, increasing physical activity and increasing plant-based food
intake, taking supplemental calcium, magnesium, potassium, folic acid and
vitamin D, and reducing homocysteine levels, sodium intake and alcohol consumption(95-97). Nutrition therapy by RD is essential in the
management of hypertension.

Nutritional care

Recommendation 10: A prerequisite for
ensuring the successful implementation of nutrition therapy is to rapidly detect
nutritional deficiencies and treat complications. Attaching great importance to
nutritional care and management.

Management
of PN infusion

Severe
patients with COVID-19 infections usually have a central venous catheter or
central venous catheterization via peripheral venipuncture, which can
administer fluids at a speed less than 200 mL/h. An intravenous infusion pump
is recommended for providing PN. Severe patients with COVID-19 infections are often
older and have weaker immunity, and are at high risk for catheter-related
bloodstream infections (CR-BSI). A continuous quality improvement plan is an
effective measure to reduce CR-BSI(98-100). Such plans should include: (1) paying
attention to hand hygiene, (2) avoiding unnecessary intubation, (3) ensuring
that there are completely sterile barrier precautions when inserting a tube,
(4) performing subclavian vein catheterization, (5) sterilizing skin using 2%
chlorhexidine ethanol solution, (6) use a chlorhexidine-containing device to
secure the catheter, (7) change wet or loose dressings in a timely manner, (8)
remove the catheter as early as possible, (9) use a commercial multi-chamber
bag, (10) if there is local redness, swelling, heat, pain or fever of unknown
origin, CR-BSI should be considered. The catheter should be removed and a catheter
tip culture should be performed. Advanced patient age and long-term retention
are independent risk factors for CR-BSI(101).

Management
of tube feeding for EN

The nasogastric route should be considered
in patients requiring short-term (2-4 weeks) EN. Endoscopic gastro/jejunostomy
is recommended for patients requiring tube feeding for more than 4 weeks. The
temperature of the EN solution should be maintained at about 40℃. Continuous infusion using an infusion pump
is recommended, with a flow rate of 20-30 ml/h at the beginning. If there is no
retention after 2 hour, the speed can be increased at a rate of 10 ml/h up to
60-100ml/h. The gastrointestinal feeding tube can be connected with a Hemovac
drain to determine whether there is gastric retention.

Suggestions for treating intolerance of EN
via a nasogastric tube include: (1) use gastrointestinal stimulants (such as
metoclopramide and erythromycin) or narcotic antagonists (such as naloxone and
alvimopan), (2) change to post-pyloric feeding.

To avoid aspiration-related pneumonia, it is
recommended to (1) raise the head of the bed to a 30-45° angle, (2) patients at
high risk of aspiration-related pneumonia or patients with positive pressure
ventilation should be given the option of using a nasal jejunal tube or having
endoscopic gastro/jejunostomy (PEG/J).

Nutritional
management of patients on a ventilator

It
was reported that 38.7% of severe patients infected with COVID-19 infections require
mechanical ventilation(1). Positive mechanical ventilation changes the
normal negative pressure in the chest, which indirectly increases the
intra-abdominal pressure and significantly weakens diaphragmatic breathing,
especially under a high driving pressure or positive end-expiratory pressure.
Therefore, nutrition therapy should be carried out step-by-step to determine
each individual’s nutritional requirements. The intestinal functions should be
carefully monitored until perfusion and oxygenation improves. A top-down strategy
for the five-step ladder principle is recommended (PN→PPN+PEN→EN), and the water
being provided should be moderately increased(102). A chlorhexidine mouthwash used twice a day
can reduce the risk of ventilator-associated pneumonia(25).

Summary

At present, the COVID-19
outbreak has put tremendous pressure on the physical health, mental health and
daily life in China as well as the whole world. Huge challenges have been
brought to world’s economic development and social order, leading to a massive
consumption of human, financial and material resources. In the absence of
specific antiviral therapy, and even if/when antiviral therapy becomes
available, improving the nutritional status and immunity of individuals are
always the most important measures for the prevention and treatment (as well as
the recovery from) infectious diseases, including COVID-19 infection. Extensive
studies have confirmed that nutrition therapy can significantly improve the
therapeutic effects of conventional treatments, shorten the length of stay in
both the hospital and ICU, reduce mortality, improve the prognosis of patients and
reduce medical costs(27, 28). According to the latest research from the
American Society of Parenteral and Enteral Nutrition, nutrition therapy saves
52 million US dollars for patients with sepsis every year, and 580 million US
dollars for patients with sepsis, gastrointestinal cancer, nosocomial infections,
surgical complications and pancreatitis(29). Therefore, in the war against COVID-19
infection, great importance should be attached to the core position and basic
role of nutritional therapy. The nutritional status should be regarded as a
basic vital sign(103), and nutritional therapy should be regarded
as first-line treatment(104) both for COVID-19 and for the majority of
human diseases. The present CSPEN consensus on nutrition
therapy for severe patients with COVID-19 infections will benefit not only
China but also the whole world and will help not only fighting with COVID-19
infections at present but also other virus infection in the future.

FUNDING

This work
was sponsored by the National Key Research and Development Program awarded to
Dr. Hanping Shi (No. 2017YFC1309200).

94.K.
Briggs Early, K. Stanley, Position of the Academy of Nutrition and Dietetics:
The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in
the Prevention and Treatment of Prediabetes and Type 2 Diabetes. J Acad Nutr Diet118, 343-353 (2018).